The Consequences of Physician-Assisted Suicide Legalization

I have been in the practice of Radiation Oncology, treating cancer
patients, for 38 years in Oregon. I have been professor and Chair
of the Department of Radiation Oncology at OHSU for the past 16 years.
I retired from full-time medical practice on July 31, 2005.

I have extensively studied Oregon's assisted suicide law since
its passage in 1994. The chief argument of the proponents of legalizing
assisted suicide has been that of "choice and personal determination".
In today's society, that is a compelling argument. However, it is
important to evaluate the consequences of the legalization of assisted
suicide and euthanasia, for euthanasia is related to assisted suicide.
We need to educate ourselves regarding the whole picture of physician-assisted
suicide. This presentation will discuss many of those consequences:

1.Legalizing assisted
suicide devalues human life, and results in a loss of protection
for terminally ill patients against doctors writing a prescription
for the sole purpose of causing their death. Assisted suicide is
a reversal of the proper roles of a physician as a healer, comforter
and consoler. Physician-assisted suicide is not compatible with those
roles.

2.Those promoting assisted
suicide send the false message that doctors can do a better job of
assisting in a patient's suicide that they can of caring for their
medical needs. I am concerned that society will reap the consequences
of that demeaning message.

3.The legalization of
assisted suicide and euthanasia can inhibit the progress of medical
advances, and tends to result in fewer efforts by the doctor to find
a solution to the patient's distress. A euthanasia doctor in The
Netherlands described a request for a consultation from a physician
whose patient had gastrointestinal obstruction. The requesting doctor
told him that "in the past in this situation, I solved it by euthanasia.
Now this patient doesn't want it, and I do not know what to do".
The consulting doctor stated: "This is my biggest concern in providing
euthanasia and setting a norm of euthanasia in medicine: that it
will inhibit the development of our learning from patients, because
we will solve everything with euthanasia." [Dr.
Zylicz, Q1533, in Select Committee on the Assisted Dying for the
Terminally Ill Bill. Assisted Dying for the Terminally Ill Bill
HL, Vol. II: Evidence, .London, The Stationery Office Limited.
April 4, 2005]

4.Once a patient has
the means to take their own life, there can be decreased incentive
to care for the patient's symptoms and needs. Michael Freeland is
an example of this. He was a depressed lung cancer patient, who had
been admitted to a mental hospital unit. When his doctors were planning
for his discharge to his home where he already had lethal drugs,
a palliative care consultant wrote that he probably needed attendant
care at home, but providing for that additional care may be a "moot
point"
because he had "life-ending medication". His assisted suicide doctor
did nothing to care for his pain and palliative care needs, but did
offer to sit with him while he took the overdose. This seriously
physically-ill and mentally-ill patient was receiving poor advice
and medical care because he had lethal drugs. [Hamilton & Hamilton,
Competing paradigms or response to assisted suicide requests in Oregon. Am
J Psychiat 2005;162:1060-1065]

5.The immunity offered
to physicians under the Oregon assisted-suicide law requires only "good-faith
compliance"
with the law. This is not a medical-legal standard of care, and is
not applicable to any legitimate medical treatment.

6.There are problems
with end-of-life care in Oregon. The national organization, "Last
Acts", issued a
"report card" in November 2002 to states regarding their end-of-life
care. Oregon was given a "D" grade for hospice (less than 1/3 of
dying Oregonians used hospice), and an "E" grade for palliative care
programs (only 20% of hospitals had palliative care programs). [Last
Acts, Press Release, November 18, 2002]
Pain management has deteriorated in Oregon. After fours years of
assisted suicide in Oregon (from June 2000 to March 2002), there
were almost twice as many dying patients in moderate or severe pain
or distress, as there had been prior to Oregon's assisted suicide
law being used. [Fromme, Tilden, Drach, Tolle.
Increased family reports of pain or distress in dying Oregonians:
1996 to 2002. J Palliative Med 2004;7:431-442]

7.Oregon's increased
use of morphine is not going to dying patients. Oregon has been a
consistently leading state in per capita use of opioids/morphine.
In recent years there has been no difference between the increased
use of morphine in Oregon and the increased use in the rest of the
United States. Researchers at OHSU reported that while there had
been a 2.5 fold increase in opioid use in Oregon in the three years
from 1997 to 1999 (the same increase as in the United States); that
inpatient morphine use at OHSU did not increase significantly for
dying patients during that time. [Tolle, Hickman,
Tilden et al. Trends in Opioid Use Over Time: 1997 to 1999. J
Palliative Med 2004;7:39-45]

8.When other states
have enacted recent new laws to ban assisted suicide or strengthen
or clarify existing bans, the per capita use of morphine increased
in each of those eleven states. [Americans for
Integrity in Palliative Care, Presentation to AMA House of Delegates
Meeting, June 11, 2003]

9.This is not about
being on or off life-support. Medical professionals and the courts
(including the U.S. Supreme Court) make a distinction between the
individual's right to refuse unwanted lifesaving medical treatment
and assisted suicide.

10.Pain is not the issue. There is not one case
in Oregon of assisted suicide being used for actual untreatable pain.
Pain can be treated. Assisted suicide has been used for psychological
and social concerns. There is scientific evidence that there is an
inverse relationship between a patient having pain and their desire
for assisted suicide or euthanasia. It is ethically appropriate and
acceptable to treat a patient for pain, even if the treatment may
shorten life; the treatment is being given to treat the pain and
not specifically to cause death.

11.Oregon assisted suicide patients have been
described by their doctors as being fiercely independent and controlling
people. They fear dependency. [Ganzini, Dobscha,
Hientz, Press. Oregon physicians' perceptions of patients who request
assisted suicide and their families. J Palliative Med.2003;6:381-390]

12.Ann Jackson, executive director of the Oregon
Hospice Association told a newspaper reporter, in describing these
patients: "In effect, they've said no to hospice. Either they don't
believe we in hospice can meet their needs, or we're not meeting
their needs " [Colburn. Suicide: Study is the
first based on interviews. The Oregonian newspaper, June 12,
2003]

13.Assistedsuicide has been described [www.wesleyjsmith.com/blog] as "a
policy of privilege". Proponents tend to be upper middle class or
higher; white, well-off, well, and worried. History has taught us
that when laws are established by and for controlling people, that
the poor and vulnerable are discriminated against. African-American
and Hispanic organizations are very opposed and fearful of the legalization
of assisted suicide because of their minority status and more limited
resources.

14.The arguments favoring assisted suicide are
demeaning to people with disabilities: Proponents of legalizing assisted
suicide say, "there are situations that are worse than death." This
has mobilized the disability community against the legalization of
assisted suicide. They have formed organizations such as "Not Dead
Yet!".

15.There are financial and societal dangers;
assisted suicide may become the only choice for some patients. There
is concern nationally and within Oregon regarding the rising costs
of health care. Financial conditions may lead to assisted suicide
as an answer to those rising costs. Oregon Medicaid, the Oregon Health
Plan, covers the costs of assisted suicide with state dollars, but
it does not cover the costs for curative or local medical treatment
for patients with cancer with a less than 5% chance of living 5 years,
even when that treatment can prolong valuable life.

16.In 2003, the Oregon Health Plan stopped paying
for medicines for 10,000 poor Oregonians; this included patients
with AIDS, bone marrow transplants, mentally ill and seizure disorders.
In 2004 and the first half of this year, an additional 75,000 Oregonians
were cut from the Oregon Health Plan, to keep the state budget balanced.
Assisted suicide may become the
"only choice" for some vulnerable patients.

17.Even if a patient has Medicare or Medicaid
health coverage, there is limited access to health care in Oregon.
Sixty percent of Oregon physicians limit or do not see Medicaid patients,
forty percent of Oregon physicians limit or do not see Medicare patients.
Seventeen percent of Oregonians are without health insurance, and
the share of Oregonians without health insurance has grown faster
than in any other state over the past four years.

18.Oregon's assisted suicide "safeguards" are
not being followed. There is no protection for the depressed or mentally
ill. In 2003 and 2004 only 5% of those dying from assisted suicide
had a mental health consultation. We have published reports of a
patient diagnosed by a psychiatrist as having dementia, and still
receiving a prescription for lethal drugs. The drug is supposed to
be self-administered and we have newspaper reports of patients being
assisted in taking the drugs, because they were not able to be self-administered.

19.The prospect of euthanasia was raised by
Mr. David Schuman, then an Oregon Deputy Attorney General in 1999,
in a letter to a state senator. He wrote that Oregon's assisted suicide
law would in effect be discriminatory because of the Americans with
Disabilities Act, because the Oregon law requires self-administration
and not everyone is capable of that.
"The assisted suicide law would be treated by the courts as though
it explicitly denied the 'benefit of a 'death with dignity' to disabled
people,"
Mr. Schuman wrote.

20. Many doctors are writing prescriptions for
lethal drugs to patients for whom they have not previously cared.
Dr. Rasmussen had reported that "75% of the patients who come to
him regarding assisted suicide are patients he has never seen before." Regarding
the "slippery slope" of assisted suicide, Dr. Rasmussen said, "I
think all involved in the Oregon law must recognize that we are on
a slippery slope, and we have to be careful with every step. But
just because it's a slippery slope doesn't mean we shouldn't go there. [Robeznieks.
Oregon sees fewer numbers of physician-assisted suicides. American
Medical News. April 4, 2005]

21.Oregon continues to have a high rate of suicides,
especially among the elderly. Between 1999 and 2002, Oregon had a
rate of suicide (not deaths from assisted suicide) among those >65
years of age, that was 6th highest in the nation and 156%
that of the national average. [Elder Suicide in
Oregon. CD Summary. Oregon Dept. of Human Services. Feb. 22, 2005]

22.There is no real monitoring of Oregon's assisted
suicides. In 2004, the prescribing doctor was present at the time
the patient took the lethal doses of sleeping drugs in only 6 of
the 37 deaths. Following Mr. David Prueitt's failed assisted suicide
attempt in January 2005, the state Department of Human Services (DHS)
publicly stated that they had "not authority to investigate individual
Death with Dignity cases - the law neither requires or authorizes
investigations from DHS,"

23.There is no evidence that legalization of
assisted suicide in Oregon has decreased the rate of physician-assisted
suicide. We do not know what the assisted suicide rate is in other
states. [Stevens & Toffler. Comment on Ganzini
and Dobscha regarding comparing rates of physician-assisted suicide
in Oregon with that of other states. J Clinical Ethics 2004;
15:363-364]

24.Oregon's "assisted suicide social experiment" is
being poorly conducted and managed. The basic Oregon assisted suicide
data for the early years has been destroyed, as noted in the following
personal communication from Darcy Niemeyer of the Oregon Department
of Human Services to me: "Unfortunately, we are unable to provide
any additional information than is currently available in our Annual
Reports. Prior to 2001, we did collect the names of physicians who
were participating. However, because of concerns about maintaining
the confidentiality of participating physicians, we began using a
numeric coding system in 2001. When we implemented this coding system,
we destroyed the identifying data from the earlier years." [D.
Niemeyer letter to K. Stevens, Feb 17, 2004]. How can we
learn from the "Oregon Experiment" when critical data has been destroyed?

As I have noted in the above examples, there are serious and dangerous
consequences to the legalization of physician-assisted suicide. It
is important for this issue to be studied in depth. I appreciate
the opportunity to participate in this discussion, and to provide
some additional information that may not be known by many Oregonians.